Pay-for-performance?

Sorry I haven’t posted in a while. Life’s been busy! Here’s a thought for you…

One of the corners on the Iron Triangle of Health Care is quality (along with access and cost), and Dr. Pauline Chen, in her piece “Getting Off the Patient Treadmill,” is questioning recent methods in increasing quality. Namely, she’s tackling pay-for-performance health care systems. The idea is that doctors and hospitals are given a budget for treating a patient and earn money based on reaching certain quality benchmarks. Dr. Chen, however, is worried about how this system—which seems to be a step up from fee-for-service—will affect the doctor-patient relationship.
By having a pay-for-performance system, doctors are encouraged (monetarily) to increase patients’ long-term health and encourage good life decisions. This could lead to patients thinking that doctors’ decisions are monetarily based—doctors, for example, may refuse more expensive, not entirely necessary treatments due to their limited budget.

I’m not sure if this is necessarily a bad thing, however. This could potentially offset unnecessary costs towards patients. Doctors are currently bogged down with the threat of malpractice (leading to expensive malpractice insurance), which causes them to order many tests, most of which are unnecessary precautions. I only mention this because my father, who’s a pulmonologist, always notes how here in America more and more physicians are simply ordering tests, tests, and more tests while, in India, doctors gain medical acumen (through seeing many patients) that allows them to diagnose easily.

This could be a positive of the pay-for-performance system; by incentivizing fewer unnecessary tests, doctors can gain a new medical acumen that could save time and allow them to dedicate more effort into increasing the long-term quality of life of the patients.

There are, obviously, potential downfalls. Doctors can, as Dr. Chen’s colleague hypothesized, refuse to administer high-cost tests for the explicit reason of saving money. Doctors could also take advantage of the system—but, as this is happening in the fee-for-service system too, this could be hard to avoid in any circumstance.

Overall, I agree with Dr. Chen—it’s hard to speculate. All of these proposed systems have pros and cons, and only quality clinical trials would inform of us the efficacy of this new idea.